Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the definitional criteria for Asymptomatic vs Mild vs Moderate vs Severe COVID-19 infection
2. Discuss the requirements for outpatient vs inpatient care for pregnant women with COVID-19 infection

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Read Disclaimer & Fine Print

NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date

SUMMARY:

SMFM has updated guidance for COVID-19 and pregnancy. Topics covered include definitions based on severity of SARS-CoV-2 infection as well as both outpatient and inpatient management. The document refers to the NIH COVID-19 Treatment Guidelines (see ‘Related ObG Topics’ for summary and link)

• Definitions
• Determining Outpatient vs Inpatient Care
• Covid-19 Treatment and Antenatal Steroids
• Antibiotics and Anticoagulation
• When to Consider the ICU
• Prone Position in Pregnancy
• Outpatient Monitoring and Care
• Antenatal Testing (BPPs and NSTs)
• When to Deliver
• Postpartum Considerations
• Other Obstetric Considerations

Definitions

Asymptomatic | Presymptomatic | Presumptive Infection

• Positive COVID-19 test result with no symptoms

Mild Disease

• Patient presents with flu-like symptoms
  • Fever | Cough | Myalgias | Anosmia
• The following features are not present
  • Dyspnea | Shortness of breath | Abnormal chest imaging

Moderate Disease

• Lower respiratory tract disease
  • Dyspnea
  • Chest imaging: Compatible with pneumonia
  • Abnormal blood gases | Oxygen saturation ≥94% on room air at sea level
  • Fever: ≥39.0 °C /102.2 °F (unresponsive to 2 acetaminophen)

Severe Disease

• Respiratory rate: >30 minute
• Hypoxia
  • Oxygen saturation: <94%
  • PaO2/FiO2: <300 mm Hg
  • Chest imaging: >50% lung involvement

Note: Early warning signs of severe disease include

• Increasing sense of dyspnea
• Cannot maintain adequate oxygen saturation
• Persistent or more frequent fevers
• Worsening of myalgias

Critical Disease

• Multi-organ failure or dysfunction
• Shock
• Respiratory failure requiring
  • Mechanical ventilation or high-flow nasal cannula

Refractory Hypoxemia

• Persistent, inadequate oxygenation and/or ventilation
  • not responsive to substantial and appropriate optimization measures
• Indicates further escalation of severity
• Extracorporeal Membrane Oxygenation (ECMO)
  • May be used in the setting of refractory hypoxemia
  • Not contraindicated in pregnancy but “should occur in a center with with significant experience in its use”

Determining Outpatient vs Inpatient Care

Outpatient Care

• 14-day self-quarantine “can be considered” if patient is symptomatic or has mild infection
• Individuals who are COVID-19 positive should wear masks at all times and should be isolated through convalescence (regardless of inpatient or outpatient)

Inpatient Care

• For patients with moderate to severe infection
• Oxygen saturation <95%
  • Exertional oxygen saturation: If saturation is ≤95% on room air with exertion, consider inpatient care
• Comorbid conditions
  • Hypertension | Gestational or pregestational diabetes (inadequate control)
  • Chronic disorders (e.g., renal or cardiopulmonary disease)
  • Immunosuppressed patients
• Patients who require inpatient pharmacologic treatments

Cytokine Storm

• Consider “cytokine storm” (also known as “cytokine release syndrome”) in a febrile patient who is unresponsive to antipyretics
• Patients with COVID-19 may express high levels of inflammatory cytokines, usually associated with deteriorating hemodynamic or respiratory status
• Scoring systems are available that include ferritin levels (high) and white cell counts (low) but these are not yet validated in pregnancy
• Diagnosis and management require a multi-disciplinary team (including ICU and ID specialists)

COVID-19 Treatment

Remdesivir

• ACTT-1 trial demonstrated that remdesivir decreased duration of disease among patients with COVID-19 who required oxygen therapy
• No known fetal toxicity
• Offer “to pregnant patients with COVID-19 meeting criteria for compassionate use”

Dexamethasone

• NIH has updated its guidance based on the RECOVERY RCT trial (see ‘Related ObG Topics’)
• Dexamethasone appears to be associated with a decreased risk for mortality among patients with COVID-19 requiring oxygen therapy, especially those on mechanical ventilation | NIH recommends against use in patients not requiring oxygen
• SMFM recommends that pregnant patients who have COVID-19 and require oxygen therapy or are on mechanical ventilation should likewise be offered dexamethasone
• Glucocorticoids required for lung maturity
  • Dexamethasone 6 mg IM every 12 hours for 48 hours (4 doses) followed by up to a total of 10 days of 6 mg
• Glucocorticoids not required for lung maturity
  • Dexamethasone 6 mg daily (PO/IV) for up to 10 days should be utilized (same protocol as in nonpregnant patients)

Monoclonal Antibodies

• Provided under Emergency Use Authorization (EUA)
  • Monoclonal: Bamlanivimab (Ly-CoV555)
  • Polyclonal Casirivimab (REGN10933) and imdevimab (REGN10987)
• Use in mild to moderate COVID-19
  • >12 years and ≥40kg
  • High risk for disease progression and/or and/or hospitalization: BMI >35 | Chronic kidney disease | Diabetes | Immunosuppressive treatment
• Safety in pregnancy
  • Inadequate evidence for or against use in the general population
  • SMFM states that “there is no absolute contraindication to their use in appropriate pregnant patients”

Antibiotics and Anticoagulation

Antibiotics

• If bacterial infection suspected, treat with appropriate antibiotics | SMFM recommends starting treatment within 45 minutes if antibiotics indicated
• Community acquired pneumonia: Ceftriaxone plus azithromycin or ceftriaxone alone
• Hospital acquired pneumonia | Severe | Mechanical Ventilation: Cefepime, meropenem, piperacillin-tazobactam, linezolid, and vancomycin can all be used in pregnancy

Anticoagulation

• Prophylactic dosing
  • ASH recommends prophylactic dosing for patients who are critically ill unless therapeutic dosing indicated (e.g., confirmed venous thromboembolism) due to increased risk of coagulopathy
  • LMWH ‘may be preferred’ due to daily dosing, which will limit exposure to healthcare personnel
• Therapeutic dosing without confirmed thrombosis in a critically ill patient
  • Consider UFH due to short half-life and reversibility with protamine sulfate
• Dosing on discharge: Controversial
  • Routine VTE prophylaxis is not recommended on discharge
  • May consider anticoagulation on discharge for patients at high risk (e.g., obesity, pregnancy, immobility, inherited thrombophilias)

Note: SMFM recommends obstetricians be aware of local institution and medical service protocols for UFH and LWMH regimens and protocols | The SMFM document has the Modified IMPROVE VTE Risk Score that can be used to guide postdischarge VTE prophylaxis (used outside pregnancy)

When to Consider the ICU

• Obtain ICU consult for the following scenarios
  • Oxygen requirements: Saturation (by pulse oximeter) does not stay ≥95% with supplemental oxygen | Oxygen requirements are increasing rapidly
  • Hypotension: MAP <65 despite attempts at resuscitation
  • New end organ insufficiency (e.g., renal, liver, cardiac, neurologic etc.)

Prone Position in Pregnancy

• Can be done during pregnancy and postpartum
• Padding/pillows may be required
• Ensure tube remains in place and secure it following rotation
• “Passive prone positioning”
  • Patient not intubated | “Theoretically” may prevent intubation
  • Positions herself either lateral or fully prone
  • Maintain approximately 2 hours in each position

KEY POINTS:

Outpatient Monitoring and Care

• Schedule a follow-up visit at least once within 2 weeks of COVID-19 diagnosis
• Telehealth or specialized COVID-19 unit are both acceptable
• SMFM recommends that patients should contact a health care provider or emergency medical services if they experience any of the following

Worsening Shortness of Breath

Tachypnea

Unremitting fever (greater than 39°C) despite appropriate use of acetaminophen

Inability to tolerate oral hydration or needed medications

Oxygen saturation less than 95% either at rest or on exertion (if home pulse oximetry available)

Persistent pleuritic chest pain

New onset confusion or lethargy

Cyanotic lips, face, or fingertips

Obstetrical complaints, such as preterm contractions, vaginal bleeding, or decreased fetal movement

Antenatal Testing (BPPs and NSTs)

• Perform for usual indications
• To limit exposures and risk of transmission
  • Consider BPP once a week vs twice weekly NSTs
  • Combining ultrasound and clinic visits

When to Deliver

Asymptomatic or Mild Infection

• “COVID-19-positive status is not an indication for delivery, and delivery should be reserved for routine obstetrical indications”
  • Mode of delivery, likewise, should be based on routine indications
• 37w0d to 38w6d
  • Expectant management until 14 days after positive SARS-CoV-2 test or
  • until 7 days after onset of symptoms and 3 days after resolution of symptoms (Note: CDC has extended transmission precautions from 7 to 10 days after onset of symptoms)
• ≥39 weeks: Consider delivery

Critically Ill Patients

• SMFM states that

It is reasonable to consider delivery in the setting of worsening critical illness

Mechanical ventilation alone is not an indication for delivery

If delivery is considered based on severe hypoxemia, other options should also be discussed, including prone positioning, extracorporeal membrane oxygenation (ECMO), and the use of other advanced ventilator methods, especially if the gestational age is less than 30 to 32 weeks

Refractory Hypoxemia

• ≥32 weeks
  • Consider delivery if it may optimize care | May be earlier based on illness severity
  • severity of illness may dictate earlier delivery
• Potential benefit due early recovery includes
  • reduction in physiological demands for patients with: COVID myocarditis | Refractory hypoxemia | Prolonged recovery
  • Option of a controlled delivery and possible avoidance of perimortem delivery if patient’s condition continues to deteriorate

Postpartum Considerations

Discharge Planning

• COVID-19 patients are at increased risk for fluid overload | Carefully monitor fluid status carefully for  24 to 48 hours
• Discharge dependent on patient’s clinical status – individualize based on clinical presentation
  • Asymptomatic, presymptomatic, mild COVID-19 (without comorbidities): May be able to recover at home following a discharge timeline
  • Severe or critical disease: Requires continued inpatient observation and management
• Following discharge
  • SMFM emphasizes that patients can deteriorate following discharge
  • Instruct patient to seek care if symptoms worsen
  • Telehealth monitoring is an option

Postpartum Pain Management

• Asymptomatic, mildly symptomatic, or moderately symptomatic who still require analgesia beyond acetaminophen
  • NSAIDs preferable to opioids
  • Individualize in the case of renal damage

Postpartum Contraception

• Postpartum tubal ligation
  • Postpone if other contraceptive alternatives are available
• Immediate postpartum LARC placement
  • IUD or implant
  • Definition of immediate: Within 10 minutes of delivery up until discharge
  • SMFM states that immediate LARC placement “can be considered as alternatives to sterilization in the setting of SARS-CoV-2 infection.”

Perinatal Depression

• ACOG recommends screening for postpartum depression
• Pandemic can exacerbate depression and anxiety
• Psychoeducation can help patients cope with stress
  • Taking breaks from news stories
  • Practicing mindfulness
  • Healthful diet and regular exercise
  • Adequate sleep

Other Obstetric Considerations

• Intrapartum or postpartum fever
  • Usual work-up if no obvious cause
  • SMFM recommends to also test for SARS-CoV-2 as per local policy and guidelines
• Preeclampsia
  • Consider testing for SARS-CoV-2 for elevated elevated AST/ALT/ thrombocytopenia if other COVID-19 risk factors are present
• Aspirin and indomethacin
  • Use for appropriate obstetric indications
  • No evidence to withhold in patients with COVID-19 infection

Learn More – Primary Sources:

SMFM: Management Considerations for Pregnant Patients With COVID-19

Related ObG Topics:

Remdesivir Emergency Authorization: FDA Update and Summary of Preliminary NIH Study Data

ARDS, Critical Care and COVID-19: ‘Surviving Sepsis Campaign’ Guidelines and Key Points

Prospective Trial Results (France): Hydroxychloroquine and Azithromycin Provide No Clinical Benefit for COVID-19

COVID-19 and Coagulopathy: ISTH Issues Guidance on Diagnosis and Management

NIH COVID-19 Treatment Guidelines

COVID-19 Guidance: Key Highlights for Healthcare Professionals

Coronavirus and Pregnancy: CDC Guidance and Professional Recommendations

COVID-19: The SMFM/SOAP Guidelines for Labor and Delivery

RECOVERY RCT ALERT: Dexamethasone Reduces COVID-19 Deaths

ACTT-1 Remdesivir RCT: Preliminary Results Now Published